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Agenda Public Meeting of the Council of Governors 18 July 2016 Oake Manor Golf Club, Oake, Taunton, TA4 1BA

Chairman: Heather Strawbridge OBE Chairman of the NHS Foundation Trust & Council of Governors

PUBLIC SESSION OPENS

1 Welcome, Introductions and Apologies for Absence Verbal Heather Strawbridge

2 Declarations of Interest Verbal Heather Strawbridge

3 A Patient’s Experience Verbal Heather Strawbridge

4 Minutes of the Public Meeting of the Council of Governors held on 21 April 2016

Paper 1 Heather Strawbridge

5 Action Point Register Paper 2 Heather Strawbridge

HOLDING THE NON EXECUTIVE DIRECTORS TO ACCOUNT

6 Report from the Chairman and Chief Executive Paper 3 Heather Strawbridge

& Ken Wenman

7

Board Agendas and Minutes including feedback from Governors:

31 March 2016

26 May 2016 (Agenda only)

Paper 4 Heather Strawbridge

8 Non-Executive Director Update Reports Verbal Heather Strawbridge & NEDs

9 Q&A with the Chairman and Non-Executive Directors Verbal Heather Strawbridge & NEDs

MEMBERSHIP AND ENGAGEMENT

10 Membership & Governor Update Paper 5 Helen Braid

GOVERNOR DUTIES

11 Policy of Engagement Paper 6 Peter Dixon

12 Quality Priorities 2015/2016 and 2016/2017 Presentation Jenny Winslade and Adrian

South

13 Feedback from the Governor Focus Conference in London, 20 April 2016

Verbal Dee Nix

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14

Governor Feedback on PPI Events:

Derriford Hospital Open Day – Sylvia Hammond

Mad Hatters Tea Party – Rae Care

WI Meeting – David Shephard

Devon County Show – Phil Ford

Royal Bath and West Show - Rae Care Mark Norbury David Shephard

Anthony Leak

Royal Cornwall Show – Sylvia Hammond

Any events not listed above

Verbal Governors

15 Non-Executive Director Recruitment Update Verbal Helen Braid

SUB GROUP REPORTING

16 Progress from Remuneration & Recommendations Panel

Verbal Heather Strawbridge &

Adrian Rutter

17 Progress from the Planning Sub Group Verbal Craig Holmes

18 Progress from Membership and Engagement Sub Group

Verbal William Thomas

ALL OTHER BUSINESS

19 Any Other Business – Items to be notified to the Trust Secretary three clear working days before the meeting.

Verbal Heather Strawbridge

PUBLIC SESSION CLOSES

Chairman: Mrs H Strawbridge OBE HS Chairman of the NHS Foundation Trust Members of the Council of Governors: Mr J Christensen JC Appointed Governor Air Ambulance Charities Mr P Walker PW Appointed Governor Fire and Rescue Mr D Hellier Laing DHL Appointed Governor Local Authorities Prof S Waite SW Appointed Governor Mental Health Partnerships Mr R Care RC Public Governor Bristol B&NES Mrs S Hammond SH Public Governor Cornwall Mr W Thomas WT Public Governor Cornwall Cllr B Deed BD Public Governor Devon Mr P Ford PF Public Governor Devon Mr A Rutter AR Public Governor Devon Mr P Young PY Public Governor Devon Mr R Day RD Public Governor Dorset

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Mr J Duffie JD Public Governor Dorset Mr C Holmes CH Public Governor Gloucestershire Mr J Pallister JP Public Governor Gloucestershire Dr C Mills CM Public Governor Isles of Scilly Mr T Beale TB Public Governor Somerset Dr A Leak AL Public Governor Somerset Mr J Liddiatt JL Public Governor Somerset Mr T MacInnes TM Public Governor Wiltshire & Swindon Mrs D Nix DM Public Governor Wiltshire & Swindon Mr N Hunt NH Staff Governor Admin & Support Mr D Shephard DS Staff Governor A&E East Mr A Peak AP Staff Governor A&E North Mr S Gough SG Staff Governor A&E West Mr S Frost SF Staff Governor UCS Mr M Norbury MN Staff Governor Volunteers Non-Executive Directors: Ms V James VJ Non-Executive Director and Chairman of the Quality Committee Mr P Love PL Non-Executive Director and Chairman of the Audit & Assurance Committee Mr Hugh Hood HH Non-Executive Director and Chairman of the

Finance & Investment Committee Officers: Mr K Wenman KW Chief Executive Mrs J Winslade JW Executive Director of Nursing & Governance Mr A South AS Deputy Clinical Director Ms H Braid HB Governance and Assurance Manager Mr P Dixon PD Governance Support Manager Miss E Mitchell EM Events and Committee Coordinator

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Minutes Public Meeting of the Council of Governors 21 April 2016 Double Tree by Hilton, Bristol City Centre Hotel, Redcliffe Way, Bristol, BS1 6NJ Chairman: Mrs H Strawbridge OBE HS Chairman of SWASFT & Council of Governors Members of the Council of Governors: Mr J Christensen JC Appointed Governor Air Ambulance Charities Mr P Walker PW Appointed Governor Fire and Rescue Mr D Hellier Laing DHL Appointed Governor Local Authorities Prof S Waite SW Appointed Governor Mental Health Partnerships Mr R Care RC Public Governor Bristol B&NES Mrs S Hammond SH Public Governor Cornwall Mr W Thomas WT Public Governor Cornwall Cllr B Deed BD Public Governor Devon Mr P Ford PF Public Governor Devon Mr A Rutter AR Public Governor Devon Mr P Young PY Public Governor Devon Mr R Day RD Public Governor Dorset Mr J Duffie JD Public Governor Dorset Cllr A Gravells AG Public Governor Gloucestershire Mr C Holmes CH Public Governor Gloucestershire Mr J Pallister JP Public Governor Gloucestershire Dr C Mills CM Public Governor Isles of Scilly Mr T Beale TB Public Governor Somerset Dr A Leak AL Public Governor Somerset Mr J Liddiatt JL Public Governor Somerset Mr T MacInnes TM Public Governor Wiltshire & Swindon Mrs D Nix DM Public Governor Wiltshire & Swindon Mr N Hunt NH Staff Governor Admin & Support Mr D Shephard DS Staff Governor A&E East Mr A Peak AP Staff Governor A&E North Mr S Gough SG Staff Governor A&E West Mr S Frost SF Staff Governor UCS Mr M Norbury MN Staff Governor Volunteers

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Non-Executive Directors: Baroness Watkins of MW Non-Executive Director and Vice Chairman of the Tavistock NHS Foundation Trust Ms V James VJ Non-Executive Director and Chairman of the Quality Committee Mr T Fox TF Non-Executive Director and Senior Independent Director Mr P Love PL Non-Executive Director and Chairman of the Audit & Assurance Committee Dr I Reynolds IR Non-Executive Director Officers: Mr K Wenman KW Chief Executive Mrs J Winslade JW Executive Director of Nursing and Governance Mr F Gillen FG Executive Director of IM&T Mr M McAuley MM Trust Secretary Ms H Braid HB Governance and Assurance Manager Mr P Dixon PD Governance Support Manager Miss E Mitchell EM Events and Committee Coordinator

No. Agenda Item Action

1.0 Welcome, Introductions and Apologies for Absence

1.1

1.2

1.3

1.4

The Chairman welcomed all to the meeting and introductions were made. Apologies for absence had been received from Adrian Rutter (Public Governor, Devon), Andrew Gravells (Public Governor, Gloucestershire), Bob Deed (Public Governor, Devon), Terry Beale (Public Governor, Somerset) and Steve Waite (Appointed Governor, Mental Health Partnerships). The Chairman informed the meeting that Andrew Gravells, Public Governor for Gloucestershire, had resigned from the Council. The Chairman informed the meeting that she was to receive her OBE on Friday 22 April and due to travel arrangements would be leaving the meeting during the lunch break. Tony Fox, Non-Executive Directors, would Chair the remainder of the meeting.

2.0 Declarations of Interest

None were declared

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3.0 A Patient’s Experience

3.1

3.2

The Chairman informed the meeting that patients were now attending the Board of Directors to speak to Directors about their experience of the Trust’s services.

Torquil MacInnes and Rae Care had attended the March 2016 Board meeting and heard the patient story and informed the meeting that the patient had been very positive about the treatment received from the Trust and was happy to help publicise the good works of the Trust.

4.0 Minutes of the Public Meeting of the Council of Governors held on 10 December 2015

4.1 The Minutes of the Public Meeting of the Council of Governors held on 10 December 2015 were agreed, subject to the following amendments:

5.3 to read “Governors to take with them”

6.1 to read “staff and patients”;

6.3 amend spelling to Gazateer;

5.0 Action Point Register

5.1

5.2

5.3

Vacancy update: Appointments had been made to the vacancies for Fire & Rescue services and Mental Health Partnerships. CCG appointments were proving difficult and work was still ongoing. The Acute Hospitals appointment was being progressed. There were two Public Governor vacancies – Gloucestershire and Bristol and Bath & North East Somerset. Audit Committee: This presentation would be taken at the July 2016 meeting, the date of which would need to be re-arranged due to diary clashes. Action: July 2016 meeting date to be confirmed and Work of the Audit Committee presentation taken at that meeting. Staying Well Service: It was noted that the Staying Well service was reported to the last Ambulance Chief Executives’ meeting and the Trust appeared to be the only Trust offering this. In addition, a recent NHS confederation visitor had been impressed by the service.

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5.4

CFR and Fire Responders: The Chief Executive provided an update on CFR and Fire Responders, in particular the use of CFRs in respect of Green calls.

6 Report of the Chairman and Chief Executive

6.1

6.2

6.3

6.4

6.5

6.6

6.7

The Chairman informed the meeting of the challenges and pressures currently being faced by the Trust in light of ever increasing demand, media coverage and CQC inspections. With regard to the NHS111 service the draft reports from the CQC and PriceWaterhouse Coopers were still awaited. Demand remained unpredictable with over 3,000 calls being received during one Sunday in March which was more than on New Year’s Day. The Chairman announced that the Trust’s research team had received a national award for the amount of research carried out and that there had been an excellent turnout at a recent student paramedics day. The Chairman informed the meeting that she must pay tribute to all staff, front line and support, as well as the Executive Team as they had all dealt admirably with an unprecedented workload. During her visits to eight stations in recent weeks, the Chairman had spoken to staff and thanked them for their efforts. It was noted that Executive and Non-Executive Directors were to be allocated specific geographical areas to enable them to link in with Governors and stakeholders to develop a deeper understanding of the needs of a particular area. Action: Schedule of geographical allocations to be circulated to Governors. The Chief Executive provided a performance update to complement the information provided to Governors in the written report. Ambulance Response Programme (ARP)

ARP was being trialled by the Trust along with Yorkshire Ambulance Service NHS Trust. It focused on patient outcomes rather than response times and the revised categories were outlined to Governors.

The way in which CFRs would operate within ARP was currently being determined.

Research had identified that any risks were outweighed by the benefits of the approach.

PD

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6.8

6.9

Should the programme lead to a permanent change in performance targets, there would be an impact of the Trust’s fleet as it would need to move to higher numbers of Double Crewed Ambulances (DCAs), although Rapid Response Vehicles (RRRVs) would still be required. It was noted that West Midlands Trust operate with around 90% DCAs and only 10% RRVs.

Service Contracts

The Chief Executive discussed the possible impact upon the Trust of any new NHS111 providers in the area as this may lead to an increase in the number of calls referred to the 999 service.

It was also reiterated that when considering whether bids should be made for services, the quality of the service that could be provided was the primary concern. .

Other issues highlighted included:

Consideration was to be given to whether a county based operational structure would be a more appropriate model for the Trust to adopt.

The Aspire website which had been launched which brought together all development and career opportunities for staff.

Only one Ambulance Trust had met performance targets during 2015/16 and it had been the busiest year in the history of the ambulance service. Challenges facing the service, including increased demand and financial pressures, were recognized at a national level. Whilst ARP would assist it would not address all issues, especially that of demand.

7.0

Board Agendas and Minutes including feedback from Governors

28 January 2016 – Agenda and Minutes

31 March 2016 – Agenda

7.1

7.2

Governors sought assurance from Non-Executive Directors in respect of the following: The current position with regard to handover delays and that the Trust was working to ensure that Commissioners saw this as an issue for the whole health community rather than just Ambulance Trusts. Governors could take assurance that the NEDs were ensuring that the Executives maintained pressure in this area. The Trust has been involved in the development of the Sustainability and Transformation Plans in Devon and Dorset as any resulting changes in health care provision would impact on the Trust. The Trust’s Right Care initiative would significantly contribute towards the aim of reducing demand on Emergency Departments.

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7.3

A Trustwide meal break policy had now been agreed following a successful trial which saw paramedics using hospital canteens for their meal breaks which reduced the number of vehicles out of action whilst crews travelled back to base. The success of this policy from the point of view of staff should be reflected in the next staff satisfaction survey.

8 Non-Executive Director Update Reports

8.1

8.2

8.3

8.4

8.5

The Non-Executive Directors provided the meeting with a verbal update on their work since the last meeting. The issues highlighted included: Tony Fox:

involvement with the procurement exercise for the St James Clinical Hub in Bristol;

working with the Executive Director of Nursing & Governance in respect of health and safety good practice;

supporting the Chairman with regard the PriceWaterhouseCoopers review to ensure that the Trust is able to act swiftly on only learning;

working with the Executive Director of HR and Organisational Development with regard to sickness and absence procedures;

attending committee meeting, SI reviews and being involved in Non-Executive Director recruitment.

TF confirmed that his role was to provide insight to the Executive Directors but also seek assurance from them at the same time. Baroness Watkins of Tavistock

This would be her last Council of Governors meeting as she was coming to the end of her term of office as a Non-Executive Director;

Chairmanship of the Quality Committee had been handed over to Venessa James;

Attendance at Finance & Investment Committee had continued;

Working with the Executive Director of HR and Organisational Development with regard to the passage of the Trades Union Bill through parliament and its impact upon deductions at payroll.

Dr Ian Reynolds

Visited two ambulance stations;

Spent time in the clinical hubs with staff;

Working with the Trust Secretary in respect of membership and engagement with a view to strengthening this.

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8.6

8.7

Paul Love

Working with the Deputy Chief Executive on year end accounting and reporting;

Meeting with PriceWaterhouse Coopers regarding the annual accounts process;

progressing the internal audit programme, including challenging the timeliness and robustness of management responses to review recommendations;

the Audit Committee had received a positive review of Board Assurance.

The update reports from the Non-Executive Directors were noted and William Thomas, in his capacity as Deputy Lead Governor, passed on the thanks and best wishes of Governors to Baroness Watkins.

9 Q&A with the Chairman and Non-Executive Directors

9.1

9.2

9.3

The Governors sought assurance from the Chairman and Non-Executive Directors on the following issues: Following the recent media coverage involving the recording of response times at South East Coast Ambulance Service, the processes in place to prevent or identify whether there were any similar issues at the Trust?

The key to ensuring a situation like this did not arise was communication and trust. The Trust Board continued to be open about achieving targets and has worked with external bodies on a range of initiatives and trials such as the ARP. Work at this level required detailed analysis with the Board being informed of any adverse impact on service delivery or patient safety.

NEDs were assured that data collected throughout trials was very difficult to override due to the way in which it is captured and this data was reported on a very regular basis.

The Trust’s internal audit programme reviews the effectiveness of compliance controls and the robustness of data collection and reporting.

The culture of the organisation is one of supporting learning from errors but not of dishonesty.

“Regarding agenda item 13 (of the January 2016 Board Meeting) “Communication and Engagement Quality and Performance”, which clearly sets out the Trust’s strategy with regard to communicating outwards, could the Board please explain how they satisfy themselves that SWASFT meets the challenges endemic to all entities wishing to reply and response to external communications promptly, appropriately and effectively, and therefore builds relationships through two-way ‘push-pull’ communications and engagement”

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9.4

9.5

The Chairman referred the meeting to the previously mentioned programme of Executive and Non-Executive Directors being allocated geographical areas to focus on which will lead to improved working relationships as this work would see them working HOSCs, CCGs and Healthwatches within their allocated areas.

The Trust had recently held an event for Healthwatches which had focused upon the Trust’s quality agenda and sought their feedback on priorities.

Community initiatives such as defibrillator launches allowed for effective stakeholder engagement.

Membership was a currently under used resource and this key access point was being reviewed.

Response times to communications were dependent upon the nature of communication as FOI requests and complaints were subject to legislative and procedural processes.

Why is the Trust not more pro-active in promoting positive stories in the media rather than responding to negative coverage?

Whilst the communications team circulated a range of positive stories to the media, there was no way of ensuring that they were used. There was also the issue of patient confidentiality which was paramount. There was a balance to be struck between being pro-active and communicating in a way appropriate for the services delivered.

The Trust has a very positive social media profile with positive comments being posted regularly on Facebook.

There was a role for Governors in promoting through Trust through public and member engagements.

Action: The Communications Team to be asked to speak to Governors about the information they report on and how they engage with the media. Could assurance be provided that the revised meal break procedure which focused crews on hospitals rather than returning to base would not impact on the appropriate level of resources being allocated to a particular area?

The Trust’s focus was always patient outcome and that activity reports could be provided on a district by district basis to enable an overview to be achieved.

Resources were allocated to where they are needed rather than on a locational basis. Commissioners were aware of what their contracts could deliver and the targets that had to be achieved.

To address the issue of finite resources, the Trust worked with other organisations, such as the Fire Service for responders, to aid in delivering the necessary response.

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10.0 Membership & Governor Updates

10.1

10.2

The Trust Secretary introduced a report which provided the meeting with an update on the Trust’s membership and Governor vacancies. The following issues were highlighted:

the development of a single public and patient engagement function which would lead on the delivery of the Membership Engagement Strategy;

the structure of the Council of Governors had been agreed by them and the Board of Directors, with the allocation of Public Governor seats being based on constituency population numbers;

how public awareness of Governor meetings and PPI events could be achieved;

the accuracy of the Governor attendance tracker. Actions:

Attendance tracker to be circulated to Governors for comment prior to its inclusion in papers.

CoG meeting schedule to be updated to the internet.

Consideration to be given to promoting Governor and PPI events on Facebook and Twitter.

PD

PD

MM/LB

11.0 Policy of Engagement

11.1

11.2

The Trust Secretary informed the meeting of the requirement for the Council of Governors to establish a Policy of Engagement with the Board of Directors which can be applied when the Council has concerns about the performance of the Board of Directors, compliance with the provider licence or other matters related to the overall wellbeing of the Trust.

The Council was asked to nominate members to a working group to develop the Policy which would comprise the Trust Chairman, Trust Secretary, a Non-Executive Director and three Governors. This group would develop the policy for approval by the Council of Governors.

Agreed:

Rae Care, Torquill MacInnes and Dee Nix join the Policy of Engagement Working Group.

A meeting of the Policy of Engagement Working Group to be convened as soon as possible.

The draft Policy of Engagement to be presented to a future meeting of the Council of Governors for approval.

MM/PD

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12.0 Council of Governors - Succession Planning

12.1

12.2

12.3

12.4

The Trust Secretary referred the meeting to the decision made by the Council of Governors (10 December 2015) to move to phased elections with effect from February 2017 to minimize the risk of losing all the experience gained in the previous three years, whilst retaining the opportunity for the Council of Governors to be refreshed with new members. At the meeting the proposed programme of phasing was considered to favour constituencies in the South of the region and had therefore been reviewed and a revised programme presented for agreement. It was noted that that there was no requirement for the Annual Members Meeting to agree any changes to the length of terms of office as this had no effect to the powers of the Council of Governors. The revised programme of phased terms of office was agreed.

13.0 Register of Interests

13.1

13.2

13.3

The Trust Secretary presented the Register of Interests of the Council of Governors.

It was noted that the publication of the register was required by legislation and that it was available to the public on request.

It was also noted that not all Governors had complied with the requirement to make their annual declaration and a request was made that this be undertaken as soon as possible.

Action: All Governors to complete their annual declaration of interests.

All Governors

14.0 Composition of the Non-Executive Directors

14.1

14.2

The Trust Secretary presented a draft policy for the Composition of the Non-Executive Directors.

The following points were highlighted:

The policy reflected the Trust’s Constitution and complied with the legislation and statutory guidance.

A review of the policy would be undertaken every 3 years as a minimum.

The Trust’s Constitution allowed for the Board to comprise a maximum of 15 Directors, but a decision was made that fewer members were sufficient.

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Agreed: That the Policy for the Composition of the Non-Executive Directors be approved.

15

The Quality Agenda:

Trust Approach

CQC

Quality Account and Report

15.1

15.2

The meeting received a presentation from the Executive Director of Nursing & Governance together with the Head of Governance in respect of the Trust’s focus on quality. Issues discussed included:

The development of the Quality Strategy which would be a co-creation with staff and patients and include a 6-8 week engagement process.

The way in which quality was developed and reported through the Trust including the work of the Quality Development Forum and the implementation of the Quality Development Plan.

How the Trust was progressing its work with Dementia and the development of the Dementia Strategy. Action: A presentation in respect of the Dementia Strategy to be made at a future meeting.

The work being undertaken by the Patient Engagement Team in respect of patients with special needs or from hard to reach groups. Action: Patient Engagement Manager to attend a future meeting to discuss the Trust’s work in respect of hard to reach groups.

Progress made in respect of the 2015.16 Quality Priorities which had been included last year’s Quality Account and Report, including reference to the Paediatric Big 6 priority which had been selected by the Council for audit.

An overview of the 2016/17 Quality Priorities which were to be included in this year’s Quality Account and Report and how these linked to the wider quality agenda. Action: 2016/17 priorities to be presented for the July 2016 meeting for consideration and selection for audit.

The priority in respect of Accessible Information and the work already undertaken by the Trust in accommodating those with sensory impairment.

An overview of the way in which the CQC now inspected NHS Trusts and the findings from these inspections so far.

The high level feedback which the Trust had received in respect of its recent NHS111 inspection and the Trust’s preparation for its major inspection in June which would cover all service lines. Action: Governors to be informed of any CQC requirements impacting on them.

HB / DP

HB / SC

JW/AS

HB

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16 The Work of the Quality Committee

16.1

16.2

Venessa James, Non-Executive Director and Chair of the Quality Committee, made a presentation to the meeting about the work of the Committee.

The presentation was noted and no questions were asked.

17 Data Quality:

17.1 Francis Gillen, Executive Director for IM&T, made a presentation to the meeting which covered a number of issues in respect of the Trust’s approval to data quality, data protection, disclosures and Governor responsibilities.

Action: Presentation slides to be circulated to Governors.

PD

18.0 Progress from Remuneration & Recommendations Panel

18.1

18.2

18.3

18.4

18.5

The Chairman informed the meeting of the recruitment plan to replace the Non-Executive Director Mary Watkins, whose term of office would end in August 2016 and that a timetable had been developed for the recruitment exercise. In response to the concerns to application documentation in previous recruitment exercises, it had been agreed that all candidates should submit a CV, together with their response to four questions, these being:

what motivated them to apply?

what key skills and experience would they bring to the Board of Directors?

what did they think they would gain from the role

what role held in the past would be most useful at the Trust? It was anticipated that this would enable the easier comparison of applications. The Panel agreed the skillset of the new NED should include an understanding of the public sector and the needs of patients. Consideration would also be given to the time a candidate could give to the role. There had been some slippage in the recruitment progression and a revised timeline would be issued to Panel members. Action: Revised recruitment timeline to be circulated to the Remuneration & Recommendations Panel It was noted that the Panel would also be required to consider the appointment of a Trust Chairman as HS final term of office would end in February 2017.

MM

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19.0 Progress from the Planning Sub Group

19.1

19.2

Craig Holmes provided the meeting with an update of the sub-group’s work and indicated that membership of the sub-group was low and new members were required.

The Group also sought corporate support for its work, in particular with regard to this year’s survey.

Action: Membership of the Sub-Group to be reviewed and support to be provided in respect of survey construction.

MM

20.0 Progress from Membership and Engagement Sub Group

20.1

William Thomas provided the meeting with an update on the sub-group’s work.

MM

21.0 Any Other Business – Items to be notified to the Trust Secretary three clear working days before the meeting.

21.1 Confirmation was sought as to the revised date for the July 2016 meeting of the Council of Governors. It was noted that some alternative dates had been identified and the confirmation of the final date would be circulated to Governors via the Noticeboard.

Action: July date to be finalised and confirmation included in the Governor Noticeboard.

PD

Signed: ________________________________________________

(Chairman of the Council of Governors)

Dated: _________________________________________________

A final, signed copy of the minutes is available from the meeting administrator on request

Council of Governors Action Log

Actions in progress

Date and Reference

Topic Action Owner Progress

11.12.2014

12.1

Membership and Vacancies

report

HS highlighted that there was still a CCG vacancy. And that the current role of the Governor representing the Fire and Safety Service was under

review. Marty to appoint a CCG Governor MM

Nominations from NEW Devon and Dorset CCGs

being finalised.

09.07.15

10.4

Membership and vacancies

MM to look at possibility of reducing the number of CCG representatives on the Council

MM Member and Governor

Update Paper – 18.07.2016

10.12.15

6.17

Staying Well Service

CoG Secretary to provide an update on the work of the Staying Well Service – how it has been managed and if it is working?

MM Agenda – 03.11.2016

Workshop

21.04.2016

5.2

Audit Committee

Work of the Audit Committee to be taken to July meeting. PL Deferred until September

2016 meeting.

21.04.2016

9.5 Q&A

Communications Team to be asked to speak to Governors about the information they report on and how they engage with the media.

MM Head of Communications to attend future meeting

21.04.16

10.2

Public Engagement

Consideration to be given to promoting Governor and PPI events on Facebook and Twitter.

MM/LB To be covered by Head of Communications at

future meeting.

21.04.16

13.3

Governor Declarations of

Interests All Governors to complete their annual declaration of interests Govs Ongoing


21.04.16

15.2

Quality Agenda

A presentation in respect of the Dementia Strategy to be made at a future meeting

HB/DP Future Agenda – tbc

21.04.16

15.2

Quality Agenda

Patient Engagement Manager to attend a future meeting to discuss the Trust’s work in respect of hard to reach groups.

HB/SC Future Agenda – tbc

21.04.16

15.2

Quality Agenda

Governors to be informed of any CQC requirements impacting on them. MM

Ongoing – as required.

As there are currently no specific requirements for Governors, proposed that

this action is closed.

21.04.16

19.2

Planning Sub-Group

Membership of the Planning Sub-Group to be reviewed and support to be provided in respect of survey construction.

MM Meeting to be arranged with

HS/MC/CH to progress.


Actions completed

Date and Reference

Topic Action Owner Progress

21.04.16

6

Board Engagement

Schedule of geographical allocations to be circulated to Governors PD Completed – included in Noticeboard 22.04.16

21.04.16

6

Governor Engagement

Attendance tracker to be circulated to Governors for comment prior to its inclusion in papers

PD Completed – included with 17.06.16 Noticeboard

21.04.16

10.2

CoG Meeting Schedule

CoG meeting schedule to be updated to the internet.

PD Completed

21.04.16

11.2

Policy of Engagement

RC /TM / DN to join the Policy of Engagement Working Group.

A meeting of the Working Group to be convened as soon as possible.

The draft Policy of Engagement to be presented to a future meeting of the Council of Governors for approval.

PD/MM Completed. Meeting took place 05.07.16 and policy

taken to 18.07.16 CoG

21.04.16

15.2

Quality Priorities

2016/17 priorities to be presented for the July 2016 meeting for consideration and selection for audit.

HB Completed – taken to July CoG

21.04.16

17.1

Presentations Presentation slides to be circulated to Governors. PD Completed – Included with Noticeboard 22.04.16

21.04.16

18.4

NED Recruitment

Revised recruitment timeline to be circulated to the Remuneration & Recommendations Panel

MM Completed – circulated 10.06.16


21.04.16

21.1

Council of Governors Meeting

July date to be finalised and confirmation included in the Governor Noticeboard.

PD Completed – included in Noticeboard 22.04.16

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Council of Governors Meeting 18 July 2016

Title:

Report from the Chairman and Chief Executive

Prepared By:

Helen Braid, Governance & Assurance Manager

Heather Strawbridge, Chairman

Ken Wenman, Chief Executive

Presented By:


Ken Wenman, Chief Executive

Main aim:

To support the presentation from the Chairman and Chief Executive at the meeting to inform the Council of Governors of the current performance of the Trust and other key issues based on the May Integrated Corporate Performance Report.

Recommendations:

The Council of Governors is asked to: (i) note further detail of the Trust’s performance contained

within the Integrated Corporate Performance Report; and (ii) raise any questions on Board actions or decisions with

Non-Executive Directors

Previous Forum:

None

This report references:

Statutory Requirements Met

The Council of Governors has a statutory duty to hold the Non-Executive Directors of the Trust individually and collectively account for the performance of the Board of Directors.

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Report from the Chairman and Chief Executive 1. Ambulance Response Programme 1.1 The Ambulance Response Programme (ARP) trial commenced on 19 April 2016.

The trial will run for 12 weeks and sees the Trust using a new pre-triage (nature of call) set of questions for 999 incidents. In addition, the call type definition has changed to Red, Amber and Green.

1.2 ARP is about achieving a more clinically focussed and patient-based set of outcome

standards – an improved experience for all patients. It will mean having more available resources, with fewer multiple allocations, to respond to life-threatening incidents. Allocating the most clinically appropriate resource to patients by taking a little more time to triage the call and increasing the use of ‘hear and treat’ and ‘see and treat’. It will create a new evidence-based set of clinical codes that better describe the patient’s problem and response/resource required.

1.3 The National Expert Reference Group are scrutinising the programme in great detail

and initial findings indicate that patients are getting a more appropriate response from the Trust and our limited resources are available to deal with the most critical patients as a priority.

1.4 The trial has already resulted in fewer overruns across the Trust as Red2 calls have

been taken out. These constituted about 36% of all activity and therefore were included in vehicles being diverted as a priority over Green calls and leaving calls outstanding at the end of shifts and causing overruns. In response to this finding the Trust will be increasing the number of double-crewed ambulances (DCAs) and reducing the number of rapid response vehicles (RRVs). In addition, specialist paramedics will be targeted at calls where we now have significant evidence that see-and-treat is a high probability.

1.5 A review of how the Trust’s performance compares with Yorkshire Ambulance

Service (YAS) has been undertaken and there are significant differences mainly due to the demand level being lower at YAS and them having shorter job time cycles as they are less rural.

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2. May 2016 – Performance Exception Overview

2.1 The Integrated Corporate Performance Report (ICPR) focuses on exceptional performance and aims to provide the Trust with an early warning of deteriorating performance. The four reporting categories assigned to individual performance metrics contained within the ICPR are as follows:

Performance in line with plan:

A&E (999) Activity levels (demand) in May 2016 was 1.66% below contracted volumes and 0.95% lower than the activity levels seen in May 2015.

Re-contact rates following treatment at scene were lower (better than) the local performance threshold;

Re-contact rates following telephone advice were lower (better than) the local performance threshold;

Ambulance calls closed with telephone advice are above (better than) local thresholds;

ROSC following cardiac arrest was above (better than) local thresholds;

Information Governance Toolkit is RAG rated as Green at the end of May 2016.

Urgent Care Service QR12: In the county of Dorset performance for Less Urgent Base Consultations and Less Urgent Home Visits were above (better than) the 95% performance target;

Urgent Care Service QR12: In the county of Gloucestershire performance for Less Urgent Base Consultations was above (better than) the 95% performance target;

Tiverton UCC performance against the 4 hour treatment time was above the 95% target;

Vehicle deep clean compliance was above (better than) local target levels in May 2016.

Compliance with Infection Prevention and Control. Early Warning:

The staff turnover rate remains high at 15.57% at the end of May 2016 (reducing to 14.52% excluding redundancies);

Staff Appraisal rates were below the internal KPI target of 85%, but showed improvement on the reported position in both March and April 2016.

Improvement Expected:

Red Performance (ARP) in May 2016 was below (worse than) the performance target of 75%;

Percentage of A&E calls abandoned and Time to Answer Calls in May 2016 were above (worse than) the local thresholds;

Ambulance incidents managed without transport to A&E department are below (worse than) local thresholds;

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Stroke patients receiving the appropriate care bundle was marginally below (worse than) the local threshold;

Outcome from STEMI PPCI, patients receiving primary angioplasty commencing within 150 minutes;

Outcome from Stroke, patients receiving thrombolysis at an hyper-acute centre within 60 minutes is below (worse than) local thresholds;

Acute STEMI patients receiving the appropriate care bundle was below the local threshold;

Outcome from cardiac arrest, survival to discharge rates, were marginally below the local thresholds;

NHS 111 Call Audit volumes are below (lower than) the target level at present, the Trust has internal improvement trajectories for both Hubs.

Urgent Care Service QR12: An improvement is expected for both the Gloucestershire and Dorset OOH performance for those measures where performance is below the national target levels;

Two PTS KPIs in the BNSSG contact are below agreed levels for May 2016;

Sickness levels across the trust are improving, but was 4.99% in May 2016 compared to a Trust target of 4.00%. However this does represent an improvement on the previous month and an improvement on the position reported in May 2015.

Escalated Performance Issue

1,899 of operational resource hours were lost to chargeable handover delays at acute hospitals in May 2016. This equates to an average of 61 hours lost per day across the Trust;

NHS 111 call answering performance is below (worse than) the 95% national KPI level in May 2016.

NHS 111 call abandonment rates were above (worse than) the national KPI level of 5% in all three counties in May 2016 in Devon and Cornwall, but were below the KPI level in the county of Dorset.

3. Recommendation 3.1 The Council of Governors is asked to:

(i) note further detail of the Trust’s performance contained within the Integrated Corporate Performance Report; and

(ii) raise any questions on Board actions or decisions with Non-Executive Directors .

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Title:

Board Agendas and Minutes

Prepared By:


Presented By:


Main aim:

To provide Governors with the following information:

Board Agenda and Minutes – 31 March 2016 attended by Rae Care, Torquil MacInnes and Bob Deed Board Agenda – 26 May 2016 attended by Dee Nix and Adrian Rutter

Recommendations:

The Council of Governors is recommended to take assurance from the range of topics considered by the Board of Directors together with the feedback received from Governors who attended the meetings and ask any questions they may have.

Previous Forum:

None



The Council of Governors has a statutory duty to hold the Non-Executive Directors of the Trust individually and collectively account for the performance of the Board of Directors.

The Board of Directors is required to provide the agenda and minutes from their meetings to the Council of Governors.

Trust Public Board of Directors Meeting – 31 March 2016 Page 1 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 31 March 2016 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge, Chairman

Members:

Mrs H Strawbridge (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Prof. M Watkins (MW), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Administration Mrs J Smalley (JS)

Opening business

No Topic Format Presenter

1 Welcome, Introduction & Apologies Apologies: Mary Watkins

Verbal HS

2 Declarations of Interest Verbal All

3 Patient Story Presentation HS

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Questions from the Public Verbal HS

7 Minutes of Previous Meeting – 28 January 2016 Paper 1 HS

8 Action Point Register Paper 2 HS

Trust Public Board of Directors Meeting – 31 March 2016 Page 2 of 2

Strategic Items for assurance

9 Integrated Corporate Performance Report Paper 3 KW

10 Corporate Risk Register and Board Assurance Framework Paper 4 JW

11 2015 Staff Survey Update Paper 5 EW

12 Patient Safety and Experience Report Paper 6 JW

13 Information Governance Year to Date Report Paper 7 FG

14 Communication and Engagement Paper 8 LB

15 Draft Regulatory Framework 2016/17 Paper 9 JW

16 Board Annual Declarations Paper 10 MM

Items for approval

17 Membership Engagement Strategy Paper 11 MM

18 Code of Conduct for Trust Governors Paper 12 MM

19 Speak Up, Speak Out Policy Paper 13 MM

20 Committee Terms of Reference Paper 14 MM

Sub Committee reporting for assurance

21 Audit Committee Assurance Report – March 2016 Verbal PL

Closing business

22

Any Other Business

Identification of New Risks (incl. Health & Safety)

Identification of New Legislation

Verbal HS

Trust Public Board of Directors Meeting – 26 May 2016 Page 1 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 26 May 2016 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge OBE, Chairman

Members:

Mrs H Strawbridge OBE (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Baroness Watkins of Tavistock (MW), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Administration Mr M McAuley (MM)

Opening business

No Topic Format Presenter

1 Welcome, Introduction & Apologies Verbal HS

2 Declarations of Interest Verbal All

3 Patient Story Presentation HS

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Questions from the Public Verbal HS

7 Minutes of Previous Meeting – 31 March 2016 Paper 1 HS

8 Action Point Register Paper 2 HS

Trust Public Board of Directors Meeting – 26 May 2016 Page 2 of 2

Strategic Items for assurance

9 Integrated Corporate Performance Report Paper 3 KW

10 Corporate Risk Register and Board Assurance Framework – BAF to Follow

Paper 4 JW

11 Patient Safety and Experience Report Paper 5 JW

12 Information Governance Year to Date Report Paper 6 FG

13 Communications update Paper 7 LB

14 ACQIs Paper 8 AGS

Sub Committee reporting for assurance

15

Quality Committee Assurance Report – April 2016

Minutes from April 2016

Paper 9 VJ

16

Audit Committee Assurance Report – March 2016

Minutes from January 2016

Paper 10 PL

Closing business

17

Any Other Business

Identification of New Risks (incl. Health & Safety)

Identification of New Legislation

Verbal HS

Trust Public Board of Directors Meeting 31 March 2016

Page 1 of 12

Minutes Trust Public Board of Directors Meeting Thursday 31 March 2015, 10.00hrs Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair Mrs H Strawbridge - Chairman Administration Mr M McAuley – Trust Secretary

Members: Mrs H Strawbridge HS Chairman Mr K Wenman KW Chief Executive Mr P Love PL Non-Executive Director Mr A Fox AF Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Mr I Reynolds IR Non-Executive Director Prof M Watkins MW Non-Executive Director Mr F Gillen FG Executive Director of IM&T Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Dr A Smith AGS Executive Medical Director Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR & OD Non Members: Lord P Tyler PT Advisor to the Board Mr M McAuley MM Trust Secretary Mr C Nelson CN Unison Mr J Fowles JF Unison Observers: Mr B Deed BD Public Governor - Devon Mr R Care RC Public Governor – Bristol & B&NES Mr T McInness TM Public Governor - Wiltshire


Page 2 of 12

No Agenda Item Action

1.0 Welcome, Introduction & Apologies

1.1 1.2

Apologies were received from Mary Watkins. Welcome to:

Rae Care, Torquil McInnes, Bob Deed – Public Governors

Ann Rees – Patient Story

Sara Coburn – Patient Engagement Manager

2.0 Declarations of Conflict of Interest

2.1 No declarations of interest were declared.

3.0 Patient Story

3.1

Ann Rees, patient, explained that she had accessed the Service through Patient Opinion but wanted to get in touch with the Ambulance service directly as they saved her life and she had used them on occasions in the past and without SWASFT she would not be there to tell the story. She shared the positive experience of how her allergic reaction was treated and could not thank staff enough. Ann was disappointed over the negative press coverage of the Trust so wanted to say thank you as the Ambulance service had supported her family on a number of occasions. KW thanked Ann for her feedback and explained how negative stories have an impact on staff, so stories like hers are very important for the Trust to hear. AGS asked what in her mind was the most important thing about the Ambulance service. Ann explained the crew who attended her and saved her life were amazing but they commented that it was nice to have a proper emergency so she was sad to hear how staff work so hard and often very late only to hear the negative side of things. She explained that Devizes can be a Bermuda Triangle when it came to emergency medical care. CN thanked Ann, explained his role and he said he would pass her feedback to the crews in the area. KW and HS thanked Ann for attending the Board and wished her well in the future.


Page 3 of 12

4.0 Report from the Chairman

4.1 4.2

HS explained there had been a lot of media coverage and the resultant pressure on staff had been immense and was pleased to see how staff had responded. HS highlighted a couple of key things that had happened since the last Board meeting:

Meeting with Neil Parrish, MP, at the Tiverton Urgent Care Centre.

Trust Research Show Case, which included national speakers and the Trust had won Awards.

Student Paramedic Conference at UWE.

Health Watch Engagement Day

Council of Governors Induction Day.

Derek Greatorex of South Devon and Torbay CCG had visited the Clinical Hub.

5.0 Report from the Chief Executive

5.1 5.2 5.3

KW, JK and AGS had a meeting with Gloucester Commissioners regarding the pressure on staff. They shared concerns and looked for solutions to the system-wide pressure that the NHS is facing locally. Concerns were raised that demand is not sustainable for staff or performance and demands within the control of the CCG to manage. KW spoke with Rob Webster, the Chief Executive Director of the NHS Confederation, to hear our perspective. Rob arranged for KW and two AACE colleagues to meet Simon Stephens. JF noted that because of the engagement with Directors, the Union was able to ensure appropriate messaging to its members.

6.0 Questions from the Public

6.1 6.2

BD asked the question about PTS in Devon due to the performance of the current provider. KW explained we would not be proceeding with the contract as the funding level is inadequate; the Trust has commercial principles around margins but the Trust could step in locally to support Commissioners locally. RC asked about demand, noting that it had been a mild winter. KW explained winter pressures didn’t really exist as a peak anymore and that the peak was more constant throughout the year due to the increased demand on the Service.


Page 4 of 12

6.2.1 6.2.2 6.2.3

CN noted on behalf of the staff the Trust’s recognition of the pressures that demand was causing. The Union also receiving feedback regarding the existing PTS provider, and the uncertain future of the contract, is an area of concern for some staff. CN was pleased to report that there had been good engagement from the Directors around the topics and changes are noticeable in staff, such as in recent SOPs. CN noted the increase in demand and the effort in the Trust to respond appropriately, including the ARP, DoD and the positive and innovative work being done, but staff were not impressed by the CCGs lack of funding for the Service.

7.0 Minutes of the Previous Meeting – 26 November 2015

7.1 The Minutes of the previous meeting of 28 January 2016 were approved as a correct record of proceedings.

8.0 Action Point Register

8.1 30/07/2015 9.3.3 Update – to be delivered in second quarter of 16/17. 28/01/2016 20.2 Action completed and has been added to the Risk Register The following actions were noted as completed:

30/7/15 9.38

24/9/15 12.4

28/1/16 5.2

28/1/16 5.3

28/1/16 6.3.3

28/1/16 14.6

28/1/16 20.4


Page 5 of 12

9.0 Integrated Corporate Performance Report

9.1 9.2 9.3 9.4 9.5 9.6

KW introduced the ICPR and explained that activity was up by 5% on last year with a significant number of hours lost to hand-over delay. KW explained he would answer any questions associated to the storyboard regarding performance presentation, but note should be taken that for the last 6 days the Trust had achieved the best performance it had in the last 2 to 3 years. This was due to the recovery measures in place which had been agreed to the end of April 2016. KW introduced the storyboard on the screen adding narrative which had been used at the Commissioners’ meeting where Jonathan Benger had been present. The storyboard covers a 4-week period and shows peaks and troughs linked to key activities. Paul Quick joined the Board meeting to talk through the storyboard and highlighted where performance measures, IT changes, staff changes, trials and the consequential drops and improvements in performance occurred. PQ had also factored in where additional changes had occurred on a national scale, such as guidance changes. The Board considered 111 to 999 call referral rates. FG confirmed we are over-triaging 111 calls in the North. KW shared with the Board that a recent survey of the A&E staff showed that over 75% staff would like to see the origin of their call. CN explained how calls are evaluated, and post-call notifications, as to whether the call was appropriate or not and that this was also being discussed with Dave Partlow to be incorporated in the ECPR. KW added that this pressure also existed with the GPs through the OOHs service. IR thanked the Trust for the presentation which was informative and well-received by the Board. HH summarised that despite more productivity demand is just too high. JK introduced the Finance Section of the IPCR: In Month 11 the Trust had a surplus of £108,000 compared to a planned surplus of over £500,000. The reduction is directly impacted by Commissioner fines which were withdrawn and re-invested. Month 11 showed signs of positive variance in service lines so it had been reinvested to give flexibility and spend on frontline resources to give staff some respite. JK noted that £100,000 is a respectable position based on the quality of our service and performance levels. The Trust had been asked to consider its financial outturn; this has been considered by FIC but was agreed to be too difficult to achieve a greater surplus at this point.


Page 6 of 12

PL noted that it was good to show investment can demonstrate performance gain. KW stated that the intention of the short-term investment in frontline staff was not to deliver a gain in performance but to give staff respite, encouraging them to take their breaks, to not overrun and have a better day. This would have been achieved alongside high levels of patient safety. HS noted that it was a small surplus but considering the number of NHS providers in deficit it was an important statement by the Trust. JK gave an update on the contract position and the Commissioner convergence principles that the Trust worked to. She explained the current investment schedule that had been put together which totaled £10.5m. JK explained the recurrent difference that existed between the two parties was £9.9m. JK explained the Commissioners’ position was that they could not afford the Commissioner convergence principles that had been signed up to and worked to in previous years. This included no recurrent funding for Right Care, which would have meant more time on scene for paramedics and the Trust absorbing all risks regarding growth in 16/17. KW explained that as a transparent organisation he was not looking to create tension with the Commissioners but needed staff to understand that it was not the Trust dedicating money to the frontline resources and that the Trust was committed to working with the Commissioners to secure the best deal possible for SWASFT, while continuing to support the whole health economy. The Union representatives both thanked KW for the honesty he had shown in the situation and reported that staff would be grateful for the Trust’s ongoing negotiations with CCG. HS confirmed that appropriate conversations would continue with the Commissioners but it was good to note the staffside support. VJ added that despite the lack of funding available it was difficult to see why those principles had been withheld as they were key levers for demand management. HS added public information films were required nationally to invest in public services and to signpost how to access them. HH added it appeared a systemic issue where urgent and emergency care was being used to absorb patients who had no alternate routes. HS asked about call stacking and delayed responses. KW explained that there had been up to 100 to 120 calls waiting with no resource available.


Page 7 of 12

9.7

This is happening on a regular basis and far too often. KW reiterated the safety policy in place where patients were called back and triaged as appropriate. KW explained that he was also being more proactive in complaint management, explaining to the public that resource had been outstripped by demand. KW said it was appropriate for the Board to monitor it. PT asked about hand-over delay and the lack of national decision. HS added that Monitor have also asked about hand-over delays. The Board discussed hand-over delays and capping of payments. NHS 111 – JW confirmed that 111 nationally have struggled for the last 6 weeks; a couple of providers have achieved the 90% call rate. Lack of primary care access is a contributing factor. The abandonment rate in February 2016 was low and we are doing what we can to manage; the service remains calm but the tender process in Devon and Cornwall adds uncertainty. Dorset works better as it is part of an integrated service. Recruitment and induction courses continue. JW added she was proud of the 111 team. CN added the engagement of staff in 111 is better than ever and all parties are doing whatever they can to make it work. HS thanked and praised the team for all their efforts.

10.0 Corporate Risk Register and Board Assurance Framework

10.1 10.2

The Risk Register has been re-formatted with nine risks with multiple casual risks and what contributes to them, and has been seen by Audit and Assurance Committee. JK advised us there was a new risk around corporate financials and reputation as well as major risks to performance and quality. All risks have been mapped to the strategic roles of the Trust. Internal Audit Report was completed on the BAF with rotation through the lower scoring risks on the BAF to ensure their Board visibility. HS commended the new approach. Action: JW to make the font bigger for the Risk Register VJ really liked the new format, noting it is easier to focus on issues. Recommended reviewing the graph for the risk profile. The Board of Directors took assurance from the Risk Register and Board Assurance Framework noting the controls, assurance and actions in place to manage the organisation’s risks.

JW


Page 8 of 12

11.0 2015 Staff Survey Update

11.1 11.2 11.3

EW presented the summary of the 2015 Staff Survey which was completed by 40.6% of staff (2% lower than 2014). Notable areas of improvement were seen in the following areas:

“immediate manager does not take positive interest in my health and wellbeing”,

“do not receive regular updates on patient /service feedback in my Directorate/Department”,

“Communication between senior management and staff is not effective”,

“dissatisfied with the extent the organisation values my work”,

“in the last month saw errors/near misses/incidents that could hurt staff”, and

“care of patients is not the organisation's top priority”. Trust engagement improved by three points with improved engagement in the North. EW talked through the improvement areas required. When comparing with other Trusts we were better on 55 questions, average on 29 and worse on 2. Working on local action plans. EW is looking at alternative ways for the survey to be completed and allowing longer for completion. Tony Fox noted the pressure the Trust is under, noting good engagement in the North. Hugh Hood noted the amazing results against the backdrop that the Trust is working in and asked for examples of the sorts of things that had led to this change. EW cited the OO structure, career pathways and career conversations. CN added the Unison conversations with staff were better including the development for SOPs. JF added from a North perspective that the new OOs and Managers are very supportive and relationships/mentoring are being developed and are being seen as supportive. EW considering incentives for completing linked to health and well-being. The Board of Directors approved the next steps including the introduction of a mixture of completion methods and an extended window of time.

12.0 Patient Safety and Experience Report

12.1 12.2

JW presented the Patient Safety and Experience Report covering November 2015 to February 2016. 16 SIs were reported in the period (0.002% of patient contact), compared to 13 for the same period last year. 12 moderate harm incidents were reported (0.0017% of patient contact)


Page 9 of 12

12.3 12.4 12.5 12.6

which is the same number as in the previous reporting period, and 504 complaints were received (0.075% of patient contact), an increase on the same period of last year when 457 were received. JW explained 3 themes were emerging: clinical care, access and waiting and communication. Confirmation bias is a new emerging theme which JW explained to the Board and will be raised with Clinicians on the next Clinician-on-reflect. As a result the Trust had been reviewing its guidance and feeding it out to staff. JW explained human factors and how people make errors, and how we use this information to identify system failures. HS added this is a Quality Account priority this year. JW advised a national expert on Human Factors would like to work with the Trust and she is in discussion with the AHSM. JW added that at the last Quality Development meeting there was a deep dive into communication and the impact that staff can have. EW is establishing a peer support network. Trust receives more compliments than complaints (669 in period). The Board noted the Friends and Family test data. JW reported that a clinical negligence claim was withdrawn during the period. Board of Directors took assurance from the Report and the Trust actions around delivering a safe service and positive service for our patients with a positive experience.

13.0 Information Governance Year to Date Report

13.1 13.2 13.3

FG presented the report which had already been presented to the Audit and Assurance Committee. FG confirmed he had filed the IG return reporting Level 2 compliance.

FOIs are up by 40 requests, achieving a 95.4% response rate. The Trust has received a number of media FOIs. The Trust has seen an increase in Data Protection requests (16% increase from 1173 to 2049).

The Board welcomed the detailed breakdown of adverse incidents labeled ‘Other’.

The Board of Directors took assurance from the information provided.


Page 10 of 12

14.0 Communication and Engagement

14.1

LB was welcomed to her first meeting. LB explained there had been lots of media coverage interest in the Trust and FOY requests. There is a lack of effective monitoring and evaluation of our reputation in the media, so LB brought a proposal to the Board for media monitoring. LB noted the short assurance report provided this time and explained she was developing a pro-active media plan which would ensure better representation and information to the Board. The Board of Directors took assurance from the communication.

15.0 Draft Regulatory Framework 2016/17

15.1 15.2 15.3

The Board of Directors reviewed the regulatory framework. Health and Safety was noted as an omission. KW requested that this be put back in. Action: JW. KW explained the Board would continue to receive more information regarding Health and Safety and that he and JW would be meeting an HSE Executive. AF confirmed that he was the Board lead for H&S and would be happy to support further.

JW

16.0 Board Annual Declarations

16.1 MM shared the Board Annual Declarations with the Board prior to their inclusion in the Annual Report. Action: MM to add PL’s declaration to the report. The Board of Directors took assurance from the disclosures.

MM

17.0 Membership Engagement Strategy

17.1 MM presented the draft Membership Engagement Strategy. The previous strategy had focused on ‘recruitment’ and this strategy focuses on ‘engagement’. HS requested one of the aims be amended to show that COG links with patient groups. Action: MM to amend as requested Ian Reynolds, as the Board lead for this area, welcomed the strategy and looked forward to seeing details of plans of how this would happen.

MM


Page 11 of 12

The Board of Directors approved the Membership Engagement Strategy.

18.0 Code of Conduct for Trust Governors

18.1 MM presented the Code of Conduct for Trust Governors which is a requirement of Monitor’s Code of Governance. The Board discussed the confidentiality section of the Code of Conduct, noting that there was no accountability to Governors as there is for Board members. Action: FG to pick up as part of his presentation to the next Council of Governors meeting. The Board of Directors approved the Code of Conduct for Trust Governors.

FG

19.0 Speak Up, Speak Out Policy

19.1 MM presented an update on the Speak Up, Speak Out Policy which has been renamed the “Whistleblowing Policy” with immediate effect. Due to the absence of national guidance on the role of Speak Up guardians, the Policy Review Alignment Group (PRAG) met and agreed to extend the Policy review date by a further 6 months, meaning that its review of this Policy will now be due in September 2016. MM confirmed this was being reported to the Board for their oversight. Ian Reynolds noted that the internal audit had a scheduled review of whistleblowing planned and suggested that review would help inform the policy review. EW welcomed this suggestion and the update was noted for assurance.

20.0 Committee Terms of Reference

20.1 MM presented the Terms of Reference for the Quality Committee and Audit and Assurance Committee. The Board requested one amendment to the Quality Terms of Reference: under 6.1 it states that the Committee will appoint a Deputy Chair. Action: MM to add that the Deputy Chair should also be a NED.

MM

21.0 Audit Committee Assurance Report – March 2016

21.1

PL gave a verbal update on the business of the March 2016 meeting. PL noted of particular interest to the Board was the internal audit report on the Board assurance framework which achieved significant assurance and the one recommendation had already been actioned.


Page 12 of 12

22.0 Any Other Business Identification of New Risks (incl. Health & Safety) Identification of New Legislation

No other business was discussed.

Signed: (Chair)

Dated:

A final, signed copy of the minutes are available from the meeting administrator on request

Council of Governors Meeting – 18 July 2016

Page 1 of 7

Council of Governors 18 July 2016

Title:

Membership & Governor Update

Prepared By:


Peter Dixon, Governance Support Manager

Presented By:


Main aim:

To provide Governors with an overview of Trust Membership, vacancies on the Council of Governors and other updates of note.

Recommendations:

The Council of Governors is asked to:

Confirm whether elections are to be held for the vacant positions in the Bristol and Bath & North East Somerset and the Gloucestershire constituencies.

Review the allocation of Appointed Governor seats prior to the commencement of the 2017 terms of office.

Previous Forum:

None.



Appendix 3 to Annex 5 of the Trust’s Constitution sets out the role of Governors in respect of developing a representative membership.

Appendix 4 to Annex 5 of the Trust’s Constitution sets out the role of the Council of Governors in respect of filling vacancies on the Council.


Page 2 of 7

Membership & Governor Update 1. Membership Overview 1.1 The Trust continues to recruit new members and will continue to target recruitment

to constituencies where we are under-represented. 1.2 Governors’ local knowledge has been used to identify additional opportunities for

PPI events in 2016/2017 as well as informing the Membership and Engagement Strategy.

1.3 Whilst the Trust is mindful of the requirement to recruit a representative

membership, the focus going forward will be on engagement as opposed to recruitment.

2. Membership Levels

Members 31.03.2015 31.03.2016 11.07.2016

Public 14,327 14,250 14,173

Staff 4,388 4,914 4,846

Total 18,722 19,164 19,019

2.1 As at 11 July 2016 the Trust had a public membership of 14,173. Whilst this figure

meets the target of 0.26%1 across the entire region previously adopted by the Trust, there are a number of individual constituencies where membership levels are lower, these being Bristol and Bath & North East Somerset; Dorset; Gloucestershire; and Wiltshire and Swindon.

Constituency Number of Governors

Minimum No. of Members required

for an election

Actual Number of Members

% of Eligible

Residents

Bristol and Bath & North East Somerset

2 320 1,225 0.19%

Cornwall 2 272 3,081 0.56%

Devon 4 580 3,176 0.27%

Dorset 2 360 1,577 0.20%

1 This figure was contained in the Trust’s Membership Strategy which has now been replaced by the Membership & Engagement Strategy.


Page 3 of 7

Gloucestershire (incl South Gloucestershire)

3 436 1,473 0.16%

Isles of Scilly 1 25 74 3.37%

Somerset (incl North Somerset)

3 375 2,538 0.38%

Wiltshire and Swindon 2 336 1,029 0.15%

3. Membership Data

Public Membership 2014/15 2015/16 2016/17 - Q1

Recruited 261 121 72

Lost 121 198 172

Net change in public membership +140 -77 -100

Staff Membership 2014/15 2015/16 2016/17 - Q1

Recruited 392 1,453 234

Lost 373 927 304

Net change in staff membership +19 +526 -70

3.1 Governors will note that the number of public members lost during the first quarter

of 2016/17 appears to be high. It should be noted, however, that this is due to a detailed membership data cleanse which has captured a number of changes from the previous financial year.

4. An Engaged Membership 4.1 The Trust recognises that members will want to have varying levels of involvement

with the Trust. Accordingly, Trust Membership is split into three levels ranging from simply receiving information through to becoming a Governor. The table below sets out the number of members signed up to each level of membership as at 11 July 2016 and how many of those members have provided an email address to enable electronic communication.


Page 4 of 7

Membership Level Number

of Members

% of Membership

Number of Email

Addresses

One – Informed

Receive newsletters and information about the Trust

11,452 80.81% 3,295

Two – Involved

Also take part in surveys, consultations and events

1,886 13.31% 871

Three – Influential

Might also consider becoming a Trust Governor

833 5.88% 475

5. Staff Governors and Membership

Staff Constituency Membership 11.07.2016

Governors

Accident & Emergency: East Division 746 David Shephard

Accident & Emergency: North Division 1,438 Alan Peak

Accident & Emergency: West Division 1,168 Stephen Gough

Urgent Care Services (inc NHS111) 679 Steve Frost

Administration, Support and Other Services

659 Neil Hunt

Volunteers 156 Mark Norbury

Total 4,846 6


Page 5 of 7

6. Public Governors and Membership

Public Constituency Membership 11.07.2016

Governors

Bristol, Bath & North East Somerset

1,225 Rae Care and Vacancy (1)

Cornwall 3,081 Sylvia Hammond and William

Thomas

Devon 3,176 Adrian Rutter, Paul Young, Bob

Deed and Phil Ford

Dorset 1,577 Robert Day and Jim Duffie

Gloucestershire (incl South Gloucestershire)

1,473 Craig Holmes, Jerry Pallister and Vacancy (1)

Isles of Scilly 74 Chris Mills

Somerset (incl North Somerset)

2,538 Terry Beale, Jeff Liddiatt and Anthony Leak

Wiltshire and Swindon 1,029 Torquil MacInnes and Dee Nix

Total 14,173 17 (plus 2 vacancies)

6.1 Following the resignation of Harriet Lupton, Governor for Bristol and Bath & North East Somerset, the Trust commenced the election process and undertook work to raise awareness of the vacancy. The Trust wrote to all members in the constituency via email and a press release was issued across the area. Regrettably there were no nominations forthcoming. Governors are aware that Andrew Gravells, Governor for Gloucestershire, has also resigned.

6.2 If the Trust were to commence an election for each of these vacancies during July,

the outcome would not be known until September, assuming that candidates stood for the seats. This would leave the two new Governors with a maximum term of office of five months.

6.3 Governors are asked to consider whether elections are to be held for each of these

vacancies in light of the short period of time remaining on the current terms of office and that the Trustwide elections for all seats will be held in early 2017.


Page 6 of 7

7. Appointed Governors

Appointed Governors Governor

Local Authorities Doug Hellier Laing

Clinical Commission Groups – North Division

Propose that these seats are merged.

Vacancy

Clinical Commissioning Groups – East & West Divisions

Appointments from NEW Devon and Dorset CCGs currently being confirmed.

Police Forces Propose that these seats are merged into a single Emergency Services appointment.

Vacancy

Fire and Rescue Services Paul Walker

Acute Trusts Vacancy

Mental Health Partnerships Stephen Waite

Air Ambulance Charities John Christensen

7.1 The Trust is currently working to ensure that the appointed vacancies will be filled. Clinical Commissioning Groups 7.2 Two nominations have been received for the East & West Divisions and these are

being progressed. CCGs in North Division have not made a nomination. 7.3 Governors have indicated that in light of the current and historic difficulties in filling

the CCG appointments, consideration should be given to the amalgamation of these seats.

Emergency Services 7.4 The Trust has received no response from the Police Forces in respect of their

vacancy. Again, due to the difficulties in appointing a Governor for the Police Forces and their lack of engagement on the matter, the CoG may wish to consider future alterations to the position. It may be of benefit to the CoG to combine the seats of the Fire and Rescue and Police Force into a new ‘Emergency Services’ appointment. This would also allow the Trust to include the Coastguard.

NHS Acute Trusts 7.5 The Trust has made contact with the Acute Trust is currently in discussion with two

Trusts regarding possible nominations.


Page 7 of 7

8. New Governors 8.1 Since the Council of Governors meeting on 21 April 2016 no new Governors have

been welcomed to the Trust.

9. Governor Attendance Report 9.1 Annex A sets out the attendance of Governors at CoG Meetings; Board Meetings;

patient and public involvement events and any additional events organised or attended by a Governor in their own area. The period covered is from 1 April 2016 to 17 June 2016. During this time there was one full Council of Governors meeting, one scheduled Board meeting and eleven SWASFT PPI events. (The extraordinary Confidential Board Meetings have not been included in this schedule.)

9.2 Following feedback as to the accuracy of the attendance tracker at the previous

meeting of the Council of Governors; the tracker was distributed with the Noticeboard on 17 June 2016, with a request that Governors check their details. As no responses were received, the tracker as circulated is attached.

10. Recommendation 10.1 The Council of Governors is asked to: 10.1.1 Confirm whether elections are to be held for the vacant positions in the

Bristol and Bath & North East Somerset and the Gloucestershire constituencies.

10.1.2 Review the allocation of Appointed Governor seats prior to the

commencement of the 2017 terms of office. Helen Braid Peter Dixon Governance & Assurance Manager Governance Support Manager

2016/2017 Governor Attendance 01/04/16 – 17/06/2016 Governor CoG % Workshop % Board Meetings (1) PPI Events Other Events

Terry Beale 0/1 0 0/0 0

Rae Care 1/1 100 0/0 0 2

John Christensen 1/1 100 0/0 0

Robert Day 0/1 0 0/0 0

Bob Deed 0/1 0 0/0 0

Jim Duffie 1/1 100 0/0 0 1

Phil Ford 1/1 100 0/0 0 1

Steve Frost 1/1 100 0/0 0

Stephen Gough 1/1 100 0/0 0

Sylvia Hammond 1/1 100 0/0 0 1

Doug Hellier Laing 1/1 100 0/0 0

Craig Holmes 1/1 100 0/0 0

Neil Hunt 1/1 100 0/0 0

Anthony Leak 1/1 100 0/0 0 1

Jeff Liddiatt 1/1 100 0/0 0

Torquil MacInnes 1/1 100 0/0 0

Chris Mills 1/1 100 0/0 0

Dee Nix 1/1 100 0/0 0 1

Mark Norbury 1/1 100 0/0 0 3

Jerry Pallister 0/1 0 0/0 0

Alan Peak 1/1 100 0/0 0 1

Adrian Rutter 0/1 0 0/0 0 1

David Shephard 1/1 100 0/0 0 1 1

William Thomas 1/1 100 0/0 0

Stephen Waite 0/1 0 0/0 0

Paul Walker 1/1 100 0/0 0

Paul Young 1/1 100 0/0 0

of 3


Title:

Policy of Engagement: Board of Directors and the Council of Governors

Prepared By:


Presented By:


Main aim:

To seek approval from the Council of Governors for the Policy of Engagement

Recommendations:

The Council of Governors is asked review and approve the Policy of Engagement

Previous Forum:

None



The NHS Foundation Trust Code of Governance

of 3

Policy of Engagement: Board of Directors and the Council of Governors 1. Background 1.1 The NHS Foundation Trust Code of Governance requires the Council of Governors

to establish a Policy of Engagement with the Board of Directors which can be applied when the Council has concerns about the performance of the Board of Directors, compliance with the provider licence or other matters related to the overall wellbeing of the Trust.

1.2 The Policy will be distinct from the procedure for dispute resolution between the

Council of Governors and the Board of Directors which is covered in Annex 8, Appendix 4 of the Trust’s Constitution

2. Development of the Policy of Engagement 2.1 At the Council of Governor meeting on 21 April 2016 it was agreed that a working

group be established to produce a draft policy for presentation at the July meeting. 2.2 The working group consisted of:

Ian Reynolds – Non-Executive Director

Dee Nix – Public Governor for Wiltshire

Torquil MacInnes – Public Governor for Wiltshire

Rae Care – Pubic Governor for Bristol and B&NES.

Marty McAuley – Trust Secretary

Peter Dixon – Governance Support Manager 2.3 The Working Group met on 5 July 2016 to draft the policy. 2.4 Several issues were discussed around the policy and these included:

The requirement for the policy to be flexible in relation to who concerns were raised to

Governance of the process

Knowledge of the Governors around licences

Escalation process 2.5 The agreements reached in respect of these issues have been incorporated into the

draft at Annex A.

of 3

3. Recommendation 3.1 The Council of Governors is asked review and approve the Policy of Engagement.

Peter Dixon Governance Support Manager

Policy of Engagement:

Board of Directors and the Council of

Governors

Version: 1

Status: Draft

Title of originator/author: Governance and Assurance Manager

Name of responsible director: Trust Secretary

Developed/revised by group/committee and Date:

Policy of Engagement Working Group 05.07.2016

Approved by group/committee and Date:

Effective date of issue: (1 month after approval date)

Next review date:

Date Equality Impact Assessment Completed

Regulatory Requirement: NHS Foundation Trust Code of Governance

(Policy of Engagement – Board of Directors and the Council of Governors)

Page 1 of 10

Trust Policy Foreword SWASFT has a number of specific corporate responsibilities relating to patient and staff safety and wellbeing which should be included within all Trust policy and strategy, as a foreword inside the front cover: Code of Conduct and Conflict of Interest Policy - The Trust Code of Conduct for Staff and its Conflict of Interest and Anti-Bribery policies set out the expectations of the Trust in respect of staff behaviour. SWASFT employees are expected to observe the principles of the Code of Conduct and these policies by declaring any gifts received or potential conflicts of interest in a timely manner, and upholding the Trust zero-tolerance to bribery. Compassion in Practice – SWASFT will promote the values and behaviours within the Compassion in Practice model which provide an easily understood way to explain our role as professionals and care staff and to hold ourselves to account for the care and services that we provide. These values and behaviours reflect the Trust’s commitment to developing an outstanding service through the conduct and actions of all staff. SWASFT will encourage staff to demonstrate how they apply the core competencies of Care, Compassion, Competence, Communication, Courage, and Commitment to ensure our patients experience compassionate care. Duty of Candour – SWASFT will, as far as is reasonably practicable, apply the statutory Duty of Candour to all reported incidents where the Trust believes it has caused moderate or severe harm or death to a patient. This entails providing the affected patient or next of kin (within strict timescales) with: all information known to date; an apology; an explanation about any investigation; written follow-up; reasonable support; and the outcome fed back in person (unless they do not want it). The only exception is where making contact could have a negative impact upon the next of kin. SWASFT employees are expected to support this process by highlighting (early) any incident where they believe harm may have been caused. Equality Act 2010 and the Public Sector Equality Duty - SWASFT will act in accordance with the Equality Act 2010, which bans unfair treatment and helps achieve equal opportunities in the workplace. The Equality Duty has three aims, requiring public bodies to have due regard to: eliminating unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act; advancing equality of opportunity between people who share a protected characteristic and people who do not share it; and fostering good relations between people who share a protected characteristic and people who do not share it. SWASFT employees are expected to observe Trust policy and the maintenance of a fair and equitable workplace. Fit and Proper Persons – SWASFT has a statutory duty not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director under given circumstances. They must be: of good character; have the necessary qualifications, skills and experience; able to perform the work they are employed for (with reasonable adjustments); able to provide information required under Schedule 3 (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). The definition of good character is not the test of having no criminal convictions but instead rests upon judgement as to whether the person’s character is such that they can be relied upon to do the right thing under all circumstances. This implies discretion for boards in reaching a decision and allows that people can change over time. Health and Safety - SWASFT will, so far as is reasonably practicable, act in accordance with the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and associated legislation and approved codes of practice. It will provide and maintain, so far as is reasonable, a working environment for employees which is safe, without risks to health, with adequate facilities and arrangements for health at work. SWASFT employees are expected to observe Trust policy and support the maintenance of a safe and healthy workplace. Information Governance - SWASFT recognises that its records and information must managed, handled and protected in accordance with the requirements of the Data Protection Act 1998 and other legislation, not only to serve its business needs, but also to support the provision of highest quality patient care and ensure individual’s rights in respect of their personal data are observed. SWASFT employees are expected to respect their contact with personal or sensitive information and protect it in line with Trust policy. NHS Constitution - SWASFT will adhere to the principles within the NHS Constitution including: the rights to which patients, public and staff are entitled; the pledges which the NHS is committed to uphold; and the duties which public, patients and staff owe to one another to ensure the NHS operates fairly and effectively. SWASFT employees are expected to uphold the duties set out in the Constitution. Risk Management - SWASFT will maintain good risk management arrangements by all managers and staff by encouraging the active identification of risks, and eliminating those risks or reducing them to the lowest level that is reasonably practicable through appropriate control mechanisms. This is to ensure harm, damage and potential losses are avoided or minimized, and the continuing provision of high quality services to patients, stakeholders, employees and the public. SWASFT employees are expected to support the identification of risk by reporting adverse incidents or near misses through the Trust web-based incident reporting system.


Page 2 of 10

CONTENTS

1. PURPOSE ....................................................................................................................... 3

2. SCOPE ............................................................................................................................ 3

3. DUTIES, RESPONSIBILITIES AND REPORTING .......................................................... 3

4. RAISING CONCERNS .................................................................................................... 6

5. PANEL FOR ADVISING GOVERNORS .......................................................................... 7

6. TRAINING REQUIREMENTS .......................................................................................... 8

7. MONITORING ................................................................................................................. 8

8. REFERENCES ................................................................................................................ 8

9. ASSOCIATED DOCUMENTS ......................................................................................... 8

VERSION CONTROL SHEET ............................................................................................. 9

(Policy of Engagement – The Board of Directors and the Council of Governors)

Page 3 of 10

1. Purpose

1.1 An open and constructive working relationship between the Council of Governors and Board of Directors is essential for an effective NHS Foundation Trust. Under-pinning such a relationship is the need for clarity on the respective roles and responsibilities of those involved.

1.2 The NHS Foundation Trust Code of Governance recommends that Trusts establish

a policy for engagement between the Board of Directors and the Council of Governors which can be applied when the Council has concerns about the performance of the Board of Directors, compliance with the provider licence or other matters related to the overall wellbeing of the Trust.

1.3 For the purposes of this policy the Trust Secretary, Chairman and Senior

Independent Director (SID) are interchangeable due to the possibility of the involvement of one of these three individuals in the concern being raised. As such, there is flexibility in the stages of escalation and de-escalation to take this into account. Advice should be sought from the Chief Executive or Chairman of the Audit and Assurance Committee if one of these individuals is involved in the concern.

2. Scope

2.1 This policy:

sets out the roles and responsibilities of the Board of Directors and the Council of Governors and how the two bodies will interact with each other for the benefit of the Trust;

describes the formal and informal mechanisms by which Governors and Directors will interact and communicate with each other;

describes the methods by which Governors may engage when they have serious concerns about the performance of the Board of Directors, compliance with the Trust’s Provider Licence, or the welfare of the NHS Foundation Trust; including escalation to the Panel established by Monitor to support Governors in their role and to which Governors may refer a question as to whether the Trust has failed or is failing to act in accordance with its Constitution.

2.2 This policy is distinct from the procedure for dispute resolution between the Council

of Governors and the Board of Directors which is covered in Annex 8, Appendix 4 of the Trust’s Constitution.

3. Duties, Responsibilities and Reporting

The Chairman 3.1 Responsible for leadership of the Trust Board, ensuring their effectiveness on all

aspects of the role and setting their agenda. The Chairman is also responsible for the leadership of the Council of Governors and works jointly with the Lead Governor in setting the agenda.

3.2 Responsible for facilitating the communication between the Board and the Council

of Governors, to ensure an ongoing dialogue which includes the information they require to carry out their duties.


Page 4 of 10

3.3 Ensures that the issues and concerns of the Governors and the members whom

they represent are communicated to the Board as a whole. 3.4 Instructs the Trust Secretary to arrange informal meetings between the Governors

and Directors outside of the Council of Governor meetings to address concerns raised, answer questions and confirm decisions made by the Board of Directors (where appropriate).

The Chief Executive 3.5 Ensures the provision of information and support to the Board of Directors and

Council of Governors. 3.6 Facilitates and supports effective joint working between the Board of Directors and

Council of Governors. 3.7 Supports the Chair in his/her task of facilitating effective contributions and

sustaining constructive relations between Executive and Non-Executive members of the Board of Directors, elected and appointed members of the Council of Governors and between the Board of Directors and Council of Governors.

The Executive Directors 3.8 The Executive Directors will make a commitment to attend meetings arranged in

light of the concerns raised by Governors, where appropriate, in order to work to allay or rectify issues raised.

3.9 When called to attend Council of Governor meetings under the Trust’s constitution

the Executive Directors will attend.

Senior Independent Director 3.10 Be available to Governors should they have concerns which have not been resolved

through contact with the Chairman, Chief Executive or Trust Secretary or for which such contact is inappropriate.

3.11 Attend sufficient meetings with Governors to listen to their views and develop a

balanced understanding of their issues and concerns. Non-Executive Directors 3.12 Maintain regular contact with Governors to understand their issues and concerns. 3.13 Make the commitment to attend meetings arranged in light of the concerns raised

by Governors, where appropriate, in order to work to allay or rectify issues raised. 3.14 Attend any meeting of the Council of Governors as requested or when called under

the Trust’s constitution. 3.15 To challenge and hold the Board of Directors to account and to seek assurance in

relation to the concerns raised by the Governors. 3.16 To seek assurance in the period following the rectification of an issue and to provide

assurance to the Governors until such a time that the issue is no longer considered relevant.


Page 5 of 10

Trust Secretary 3.17 Establish a policy for engagement with the Board of Governors for those

circumstances when they have concerns about the performance of the Board of Directors, compliance with its provider licence or other matters related to the overall wellbeing of the Trust. Maintain and update this policy to ensure that it remains effective and compliant with legislative requirements.

3.18 Be the first point of contact for the Lead Governor, Deputy Lead Governor or any

Governor or group of Governors who wish to raise a concern covered by this policy. 3.19 Arrange informal meetings between the Governors and Directors outside of the

Council of Governor meetings to address concerns, answer questions and confirm decisions made by the Board of Directors (where appropriate) where requested to do so by the Chairman.

3.20 Have oversight of the governance of the escalation process. The Trust Secretary

will record the concerns raised by the Governors and ensure that the matter is escalated and deescalated as necessary. The recording of this process will be reported back to the Governors at Council of Governor meetings.

Council of Governors 3.21 Commit to raising and continuing to raise their concerns in an appropriate way. 3.22 Communicate with the Board of Directors in an open and transparent way in the

interest of the members, public, staff and patients. 3.23 Hold the Non-Executive Directors to account in relation to receiving assurance on

the risks pertaining to the Trust and the actions of the Board. In addition assurance should be sought over solutions implemented following concerns raised by the Council of Governors.

3.24 Further to a concern being addressed seeking further assurance from the Non-

Executive Directors at regular intervals until such a time that the concern is no longer believed to be relevant to the Trust.

3.25 Ensure that the Council of Governors as a body are satisfied with the outcome

following the raising of a concern.

Lead Governor 3.26 Raise concerns through the most appropriate channel through the Trust Secretary,

Chairman or SID. 3.27 Work positively with the Chairman to support the undertaking of all duties and

responsibilities in leading the Trust and the Council of Governors. 3.28 Act as the point of contact between the SID and the Council of Governors. 3.29 Work collaboratively with the Trust Secretary and Chairman in matters such as

meeting agenda planning and concerns raised by the Governors.


Page 6 of 10

Governors 3.30 Individual Governors have a responsibility to act in accordance with this policy, to

raise concerns (as defined in this policy) and to assure themselves that issues have been resolved.

3.31 To escalate concerns raised in accordance with this policy through the appropriate

channels. 3.32 To attend, participate and abide by the outcome of the vote in relation to the

resolution or escalation of a concern.

4. Raising Serious Concerns 4.1 The process of raising serious concerns is tiered in order for the concern to receive

the appropriate level of response from the Trust. Tier 1 4.2 Governors should raise any concerns with the Lead Governor who will raise them

with the Trust Secretary who may, in the first instance be able to resolve the matter informally. For the purposes of this policy, a concern must be directly related to:

the performance of the Board of Directors;

compliance with the Trust’s Provider Licence; or

other matters related to the overall wellbeing of the Trust. Tier 2 4.3 Where the Trust Secretary has been unable to resolve the concerns and/or has

recommended that they be taken to the Chairman, the Trust Secretary or Lead Governor will raise the concern with the Chairman and make a request for a meeting to discuss and resolve

Tier 3 4.4 If the concern is in relation to the Chairman or if the Chairman has not been able to

resolve the concern, the matter is escalated to the SID. The SID will then investigate the concern.

4.5 Following completion of the investigation of the matter the Chairman or SID shall

meet with the Governor(s) who raised the concern to discuss their findings as soon as is reasonably practicable. Following this meeting there are the following possible outcomes:

The Governor(s) is satisfied that their concerns have been resolved in the course of the meeting and the matter will be de-escalated for monitoring while the necessary actions are taken. Once the actions are complete the Chairman, SID or Trust Secretary as appropriate will present a report to the next Council of Governors meeting. The Council of Governors will vote on their satisfaction of the outcome and the concern will be either closed or kept open and re-investigated.

The Governor(s) is satisfied that their concerns have been resolved in the course of the investigation. The Chairman shall write a report on the concerns and the action taken and present it in the next Council of Governors meeting.


Page 7 of 10

The Council of Governors will vote on their satisfaction of the outcome and the concern will be either closed or kept open and re-investigated.

If the matter is not resolved to the satisfaction of the Governor(s), the Lead Governor, Trust Secretary, Chairman or SID as appropriate shall escalate it to the next Tier of the process for further scrutiny.

Tier 4 4.6 Upon reaching Tier 4 of the process the Governor(s) who raised the concern and

the Lead Governor will meet with the Non-Executive Directors ahead of a Confidential Meeting of the Board. This meeting will provide the forum for the Governor(s) to directly address the Board in relation to their concerns. Following the Board meeting there are the following possible outcomes:

The Governor(s) is satisfied that their concerns have been resolved in the course of the investigation. The Non-Executive Directors shall write a report on the concerns and the action taken and present it in the next Council of Governors meeting. The Council of Governors will vote on their satisfaction of the outcome and the concern will be either closed or kept open and re-investigated.

The Governor(s) is satisfied that their concerns have been resolved in the course of the meeting and the matter will be de-escalated for monitoring while the necessary actions are taken. Once the actions are complete the Chairman, SID or Trust Secretary as appropriate will present a report to the next Council of Governors meeting. The Council of Governors will vote on their satisfaction of the outcome and the concern will be either closed or kept open and re-investigated.

If the matter is not resolved it is escalated to Tier 5.

Tier 5 4.7 If the matter is not resolved to the satisfaction of the Governor(s), the Trust

Secretary shall call an extraordinary meeting of the Council of Governors as soon as is reasonably practicable in accordance with the Council of Governors Standing Orders to consider the matter further. That meeting may resolve to take no further action or to consider referring the matter to the Monitor Panel in accordance with Paragraph 19 of the Constitution. The extraordinary meeting of the Council of Governors will be minuted in order to record the outcome of the decision.

Oversight 4.8 All progress of the concern will be recorded by the Trust Secretary and will be

included in the annual report to the council of Governors on the use of this policy.

5. Panel for Advising Governors 5.1 Monitor has a ‘Panel for Advising Governors of Foundation Trusts for the escalation

of issues and concerns. The Council of Governors should only consider referring a question to the panel in exceptional circumstances, where there is uncertainty within the Council about whether the Trust may have failed, or is failing, to act in


Page 8 of 10

accordance with the Trust’s Constitution or with Chapter 5 of the 2006 Act, and this uncertainty cannot be resolved through repeated discussions with the Chair or another Non-Executive Director.

5.2 The Council of Governors may refer a question to the Panel if more than half of the

members of the Council of Governors present and voting at a meeting, approve the referral.

5.3 The Panel is not able to answer operational questions or act as an independent

arbitrator between the Council of Governors and the Board of Directors.

6. Training Requirements

6.1 All members of the Council of Governors receive an induction and take part in ongoing development workshops which provide guidance on Trust policies and procedures.

6.2 Bi-annual training will be provided by the Trust Secretary in relation to the

Constitution and License agreements in order to ensure an understanding by the Governors. This training will include this policy and the associated process.

7. Monitoring

7.1 The Trust Secretary will complete an annual audit to identify how the policy has been implemented to provide assurance that it has been followed correctly. This review will form a report to the Council of Governors.

7.2 The policy will be reviewed following any amendment to the legislative and

regulatory requirements governing engagement between the Board of Directors and the Council of Governors and, in any event, no less than every three years.

7.3 This policy and any new versions must be approved by both the Council of

Governors and Board of Directors.

8. References

NHS Foundation Trust Code of Governance

Your Statutory Duties: A Reference Guide for NHS Foundation Trust Governors

Director-Governor Interaction in NHS Foundation Trusts: A Best Practice Guide for Board of Directors

Health & Social Care Act 2012

9. Associated Documents

9.1 The following documents should be read in conjunction with this policy:

Trust Constitution

Code of Conduct for Governors

Code of Conduct for Directors

Version Control Sheet

Version Date Author Summary of Changes

1

June 2016 Governance and Assurance Manager

New Policy